Making Health Systems Work for the Poor

Increasing Access to Institutional Deliveries Using Demand and

Supply Side IncentivesElizabeth Ekirapa-Kiracho

Makerere University School of Public healthResearch Coordinator, FHS Uganda

XII Ascon, Dhaka

Outline of the presentation

Introduction Access to maternal health

services in Uganda Increasing access to services for

the poor The Intervention Focus on the poor

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Introduction •

• The poor more predisposed to ill health

• The poor have reduced access to preventive and curative interventions

• Gaps in maternal mortality between rich and poor

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Increasing access to services for the poor

• New innovations in financing hold promise for improving access to the poor

CBHI/Subsidized health insurance Conditional cash transfers Equity funds Vouchers Provider subsidies

[Gwatkin et al (2004),Jacobs et al (2005),Lagarde et al (2007),Peters et al (2007)]

Interventions that increase access

Systematic & intensive approaches to delivering effective health care

Improvement in access Prompts to encourage utilization Combination of approaches Multidisciplinary approaches Expressed/ identified needs Involve peers

5[Arblaster et al ( 1996), Victoria et al ( 2007) ]

Why maternal health services?

• Maternal mortality has been almost stagnant for the past 2 decades

Maternal mortality ratio 435 per 100,000

• Fifth MDG – reduce by 75%• Over 80% of maternal deaths are

due to five direct causes, each of which require facility-based care

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.

Why maternal health services?

• Low delivery in health facilities 38% in 1995 and 42% in 2006 • Inequities in access to delivery care 79% urban areas & 36 % rural 75% highest quintile 27% lowest

quintile• Most interventions – Supply side

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.

The intervention

?

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Demand and supply side initiatives

Demand side - Performance based funding approach

- Patients decide where to seek services, this determines the amount of reimbursement

Supply side Health system strengthening

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Aim

• To increase institutional delivery and by so doing contribute in reducing maternal mortality (MDG 5) in Uganda and the regional countries

• Promote the implementation of evidence based strategies

Specific Objectives

• Assess the effectiveness of a voucher system in increasing deliveries at public, PNFP and PFP health facilities

• Assess the effectiveness of a voucher system in increasing deliveries among the poor at public, PNFP and PFP health facilities

• Estimate the incremental cost of implementing a voucher system for increasing deliveries at health facilities

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Methodology

Cluster randomized trial

4 sub-districts (2 intervention and 2 control)

Intervention: Voucher for transport and maternity services

Methodology

Primary outcome: % change in the proportion of women delivering in health facilities in the intervention and control areas

Secondary outcomes Birth outcomes Number of ANC visits Number of post natal visits

Methodology

Analytical method: Difference in differences analysis

The difference of differences of the results from the intervention and control sites

Obtained from baseline and end line surveys

Main activities during the intervention

Stakeholder Consultation Needs assessment Baseline survey Training Piloting of the intervention Implementation Endline survey Dissemination

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Barriers to the poor using services

• Cost• Long distances and lack of

transport• Attitudes of health workers and

other quality related issues• Informal payments• Preference for traditional birth

positions/ attendants[Amooti et al (1997); Atuyambe et al (2005;) Kyomuhendo et al (2003); Munaaba (1995);Waiswa ( 2008)] 17

Focus on the poor - Implementation in rural areas

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Allow choice -Public and private

• Choice Choice

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Increase awareness

• Sensitization within the community to inform them about the intervention

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Performance based method of payment

• Address quality issues

• Informal payments

• Incentives

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Removal of transport and cost barriers

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Locally available transport

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Accessing services – Multiple problems

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Increasing access to institutional delivery

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Acknowledgements

DFID FHS Partner

Institutions Researchers

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Referances Arblaster l, Lambert m, Entwistle V, Forster M, Fullerton D Sheldon T, Watt

I. A systematic review of the effectiveness of health service interventions aimed at reducing inequalities in health. J Health Serv Res Policy. 1996 Apr;1(2):93-103.

Amooti,, B. (1997). Factors influencing choice of delivery sites by pregnant mothers in Rakai district, Uganda. . Kampala, Makerere University School of Public Health. Master of Public Health.

Atuyambe, L., F. Mirembe, et al. (2005). "Experiences of pregnant adolescents - voices from Wakiso district, Uganda." Afr Health Sci 5(4): 304-9.

Gwatkin, D. R., A. Bhuiya, et al. (2004). "Making health systems more equitable." Lancet 364(9441): 1273-80.

Jacobs, B. and N. Price (2005). "Improving access for the poorest to public sector health services: insights from Kirivong Operational Health District in Cambodia." Health Policy and Planning 21(1): 27-39.

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Referances Kyomuhendo, G. B. (2003). "Low use of rural maternity services in Uganda:

impact of women's status, traditional beliefs and limited resources." Reprod Health Matters 11(21): 16-26.

Lagarde, M., A. Haines, et al. (2007). "Conditional cash transfers for improving uptake of health interventions in low- and middle-income countries: a systematic review." JAMA 298(16): 1900-10.

Munaaba (1995). Factors which influence mothers choice of location of child birth in Pallisa district, Uganda. Kampala, Makerere University School of Public Health. Masters in Public health.

Peters, D. H., A. Gary, et al. (2007). "Poverty and Access to Health Care in Developing Countries." Ann N Y Acad Sci. 2007 Oct 22 [Epub ahead of print].

UBoS (2007). Uganda demographic and health survey, 2006. Calverton, Maryland, USA.

Victoria et al .JAMA. 2007 Oct 24;298(16):1900-10. Waiswa, P., M. Kemigisa, et al. (2008). "Acceptability of evidence-based

neonatal care practices in rural Uganda - implications for programming." BMC Pregnancy Childbirth 8: 21.

 

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Thank you for listening Good ending slide

[Thank you for listening] 29